BPD Management from you experience.

Heidi · Aug 21, 2002

Hi from NZ

We too have no real agreement or policy. We have one client who is at the severe end of the spectrum and after many years the district health board, police, A&E, community mental health, acute inpatient have all agreed to develop a specific plan which will be distributed to the above. Clear concise and consistant and the risk is across the board rather than with one individual. It is time consuming and challenging but its a start. It is only one patient mind you, hopefully it is the beginning of the norm for such clients/patients.

Orca, ADN, ASN, RN · Aug 23, 2002

There probably never could, or should, be a standard policy for dealing with specific types of psychiatric illnesses. Psychiatric nursing is as much art as science. Two patients can have identical diagnoses and virtually identical symptoms, but require entirely different treatment methodologies.

Some things I have found effective with borderlines:

1. Set limits and stick to them.

2. Do not allow them to dominate discussion in groups and casual coversations. Borderlines can often be verbally aggressive, and this may cause more timid patients to withdraw and reduce their interaction, which compromises their recovery.

3. Remove them from the area if their behavior warrants it (their continual griping and challenging staff can have detrimental effects on others if left unchecked).

4. Reinforce desired behaviors. Borderlines crave positive attention, but often behave in a manner that virtually ensures that they do not get it - "proving" their self-concept that others do not like them.

5. Use reflection, and let them know how they are perceived. If appropriate, give them an example of a way they can respond that would be received more positively.

6. Have the patience of Job (which is often far easier said than done).

7. Remove yourself from the situation if you feel that your patience is reaching its limit. Losing your temper with them is of no benefit, and this can happen very easily. Let someone else take the point in dealing with them if you need a break.

sjoe · Oct 5, 2002

To overgeneralize--VERY strict rules, boundaries, and limits that are VERY strictly enforced by EVERY staff member ALL the time. (and don't expect much long-term change in the patient)

Spazzy Nurse, RN · Oct 10, 2002

To add to Orca's wonderful list and to second what Sjoe said, consistency is really key. There really is no one way (or even two ways :) ) to deal with a person having this DX...... sure is a trip trying though, isn't it?

Orca, ADN, ASN, RN · Oct 10, 2002

sjoe makes an excellent point about consistency, and about all staff being of the same mind when dealing with borderlines. They are master staff splitters, and if the staff do not communicate with one another, they will soon have you contradicting each other. Communication among staff is paramount.

Example: Staff have set limits with a borderline regarding monopolizing the television in the patient activity area. Borderline exceeds the limit. Staff person A reiterates the agreement. Borderline says, "Staff person B let me have more time yesterday, because I did not disrupt group." Staff person B happens to be off duty today, and you did not work yesterday. Borderline knows this, and uses it to his/her advantage. The argument sounds plausible, but you are unsure whether it is true or just a clever manipulation. You do not know, unless it has been specifically communicated, whether the standards staff are using have been modified within the last day or two. Borderline has created doubt, and also a situation in which one staff person may contradict the limits set by others.

What would really delight the borderline in this scenario would be if it creates an argument among staff. Many of them, perhaps most, seem to thrive on creating chaos.

CliveUK · Nov 2, 2002

Another thing I would add to Orca's list is not to forget that people don't just become "borderlines" - quite often it is a result of an horrendous upbringing including sexual and physical abuse and all the other forms of torment adults can inflict on children. Yes, it is hard to nurse these people, but I find remembering the above enables me to value the person behind the behaviour.

maureeno · Nov 4, 2002

to Orca's list I would add use humor to deflect tension and be genuine. It always helps to find something you can like about a person. I remember one night shift when a 450 lb. pt. decided to get up at 2 am. and do floor excercises and then of course could not get herself up off the floor: for a few horrible seconds all I saw was a mess of flesh writhing on the floor and then I forced myself to notice what wonderfully soft skin she had. this freed me to shake off my disgust and dismay and matter of factly find a chair and cue her on how to get up.

kaysrca · Dec 15, 2002

BPD, consistency is definately the answer as well as limit setting. In the state hospital I work in there are more and more BPD patients ,seems like that is all the new patients we receive.

sanakruz, ADN · Dec 19, 2002

I have heard "talk" that with the next DSM BPD is going to be reclassified as an Axis I dx.

This makes sense if you look at the impact these individuals have on the "system"

Clive is so right. Borderlines are made, not born.

To me that's the good news.I have seen folks make wonderful headway 1.When their dx is shared with them 2. They are consistantly told they will be assisted in their recovery, that they dont have to do it alone and 3.They have the strength to reach their goals.

These BONE SUCKERS, as I (sometimes) affectionately call them, are here to stay.

CliveUK · Dec 19, 2002

Dialectical Behaviour Therapy has been shown to be effective by a number of research studies. Of course, it's unrealistic to expect ALL the nurses in your work place could be trained up to deliver this therapy. But if it's a particular problem in your area and a lot of patients present with it, you might have a case for a dedicated specialist nurse.

Here's a link: -

http://www.priory.com/dbt.htm

Kikumaru · Jan 1, 2003

Not to change the subject but I once spoke to a psychiatric resident who stated that BPD is often misdiagnosed as Bipolar Disorder. He said that the treatments and management were the same but stated that its onset is usually later in life. Can anyone offer input on this subject?